Patient Screening Questionnaire for Solara Wellness Center
Please fill out this form to help us understand your health needs and prepare for your appointment.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What state will you be physically located in at the time of your appointment?
*
Please Select
Colorado
Arizona
Other
What service are you primarily seeking?
*
Please Select
Functional Medicine
Hormone Optimization
Weight Loss
Gut Health
CIRS / Mold Illness
Other
Are you willing to participate in a cash-pay practice?
*
Yes
No
Do you understand that Solara Wellness Center does not bill insurance?
*
Yes
No
Are you seeking a provider who bills Medicare or Medicaid?
*
Yes
No
Briefly describe your primary health concern.
*
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